Documenting “Right Now”
In the Moment…
When assisting in documentation training for EMS providers, a common emphasis is made to continually reinforce the necessity of documenting the patient’s condition right now in the Patient Care Report.
We find it especially important to stress this important concept when educating providers who are handling a fairly consistent volume of routine, non-emergency transports. But, the concept applies to emergency/9-1-1 trips as well.
“At the time of transport…”
Of course, as usual, we refer to the Medicare standard to set the pace for our discussion as we do in most cases.
The Center for Medicare and Medicaid Services (CMS) National Payment Policy for ambulance services begins with this key sentence.
“Medicare covers ambulance services only if furnished to a beneficiary whose medical condition at the time of transport is such that transportation by any other means would endanger the patient’s health.” (highlight added for emphasis).
Many of us miss the importance of the five words highlighted above.
As EMS providers (and even EMS billers) we tend to focus on the patient’s long-term condition severity and try to rationalize that all transports are medically necessary based on the patient’s overall medical condition for a length of time.
While past medical history plays a role in explaining the medical necessity and chronic conditions contribute to the EMS scenarios we are part of, they are not to be confused with the immmediate need to document what is going on with the patient at the time of transport. What’s happening with the patient in your presence is the final word on whether the patient requires ambulance transport or could possibly be transported by another means (car, wheelchair van).
Requested vs. Required
Globally, we tend to morph into an “emergency” mindset. Just because an ambulance is requested, even in a 9-1-1 setting, does not always translate into an ambulance is required.
A patient may be chronically ill, may feel ill over time for many days, months even years and yet still can be safely transported to and from locations without his/her health being endangered.
The EMS provider’s documentation must focus on painting a picture in words regarding the patient’s condition in the very moment that the EMS provider is in the patient’s presence. Using descriptive and specific words it is incumbent upon all EMS field providers to clearly, clinically and truthfully document the patient’s condition which in turn spells out without any doubt that transportation by any other means is contraindicated if a bill is to be submitted to Medicare and/or other insurance payers who use follow the principles of the CMS policies.
Documentation = Validation
The EMS provider’s documentation in the Patient Care Report acts as in validation of the patient’s need for ambulance based on the described medical necessity of the patient’s condition at the moment of transport.
Laser focus must be placed on the patient’s condition in the moment.
So, a chronically ill patient would be noted to be in such a condition at the time of interaction with the patient that leaves no doubt the patient can only be moved by a qualified ambulance crew and vehicle.
While it’s important to explain that your end-stage cancer patient has a long history of complications from his/her extended illness, the heart of your documentation will be to explain in detail why your ambulance was requested to transport the patient today.
Maybe your patient has lapsed into unconsciousness. Today, your patient’s breathing difficulties reached the point such that the patient can no longer maintain oxygen saturation levels to sustain life without your intervention. Cancer has robbed your patient of the ability to sit upright for the length of transport due to worsening contractures of his/her joints and over deconditioning as the cancer progresses throughout his/her body.
These are the details that you’ll be noting in your PCR, read and interpreted by your billing office staff, to create an iron-clad case of medical necessity requiring ambulance transport such that transportation by any other means would endanger the patient’s health.
In the end, only the EMS provider out there on the street can ultimately collect and transcribe the correct information into the PCR to create the case for proper billing of the claim. Focus on the “right now” and you’ll fulfill your documentation obligation every time!
